Search results for: surgical drain

Authors: Ana Bermudez de Castro Muela, Xiomara Santos Salas, Silvia Cayon Somacarrera

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The aim of this review is to explain what is the intracranial hypotension and its main causes, and also to approach to the diagnostic management in the different clinical situations, understanding radiological findings, and physiopathological substrate. An approach to the diagnostic management is presented: what are the guidelines to follow, the different tests available, and the typical findings. We review the myelo-CT and myelo-RM studies in patients with suspected CSF fistula or hypotension of unknown cause during the last 10 years in three centers. Signs of intracranial hypotension (subdural hygromas/hematomas, pachymeningeal enhancement, venous sinus engorgement, pituitary hyperemia, and lowering of the brain) that are evident in baseline CT and MRI are also sought. The intracranial hypotension is defined as a lower opening pressure of 6 cmH₂O. It is a relatively rare disorder with an annual incidence of 5 per 100.000, with a female to male ratio 2:1. The clinical features it’s an orthostatic headache, which is defined as development or aggravation of headache when patients move from a supine to an upright position and disappear or typically relieve after lay down. The etiology is a decrease in the amount of cerebrospinal fluid (CSF), usually by loss of it, either spontaneous or secondary (post-traumatic, post-surgical, systemic disease, post-lumbar puncture etc.) and rhinorrhea and/or otorrhea may exist. The pathophysiological mechanisms of hypotension and CSF hypertension are interrelated, as a situation of hypertension may lead to hypotension secondary to spontaneous CSF leakage. The diagnostic management of intracranial hypotension in our center includes, in the case of being spontaneous and without rhinorrhea and/or otorrhea and according to necessity, a range of available tests, which will be performed from less to more complex: cerebral CT, cerebral MRI and spine without contrast and CT/MRI with intrathecal contrast. If we are in a situation of intracranial hypotension with the presence of rhinorrhea/otorrhea, a sample can be obtained for the detection of b2-transferrin, which is found in the CSF physiologically, as well as sinus CT and cerebral MRI including constructive interference steady state (CISS) sequences. If necessary, cisternography studies are performed to locate the exact point of leakage. It is important to emphasize the significance of myelo-CT / MRI to establish the diagnosis and location of CSF leak, which is indispensable for therapeutic planning (whether surgical or not) in patients with more than one lesion or doubts in the baseline tests.

Keywords: cerebrospinal fluid, neuroradiology brain, magnetic resonance imaging, fistula

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Authors: R. Fernandez-Saavedra, M. B. Gomez-Mancebo, D. Gomez-Briceno

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The gradual corrosion of PWR (Pressurized Water Reactor) feedwater, condensate and drain systems results in the inevitable liberation of corrosion products, principally metallic oxides, to the secondary circuit. In addition, other contaminants and impurities are introduced into the makeup water, auxiliary feedwater and by condenser leaks. All these compounds circulating in the secondary flow can eventually be transported to steam generators and be transformed into deposits on their surfaces. Deposits that accumulate on the tube sheet are known as sludge piles and when they consolidate and harden become into hard sludge. Hard sludge is especially detrimental because it favors tube deformation or denting at the top of tube sheet and further stress corrosion cracking (SCC). These failures affect the efficiency of nuclear power plants. In a recent work, a model for the formation and consolidation of hard sludge has been formulated, highlighting the influence of aluminum and silicon compounds in the initial formation of hard sludge. In this work, an experimental study has been performed in order to get a deeper understanding of the behavior of Al and Si species in hard sludge formation and consolidation. For this purpose, the key components of hard sludge (magnetite, aluminum and/or silicon sources) have been isothermally autoclaved in representative secondary circuit conditions during one week, and the resulting products have been chemically and structurally characterized by XRF and XRD techniques, respectively.

Keywords: consolidation, hard sludge, secondary circuit, steam generator

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Authors: Jonathon Bailey, Neil Bressloff, Nick Curzen

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Transcatheter Aortic Valve Implantation (TAVI) devices are stent-like frames with prosthetic leaflets on the inside, which are percutaneously implanted. The device in a crimped state is fed through the arteries to the aortic root, where the device frame is opened through either self-expansion or balloon expansion, which reveals the prosthetic valve within. The frequency at which TAVI is being used to treat aortic stenosis is rapidly increasing. In time, TAVI is likely to become the favoured treatment over Surgical Valve Replacement (SVR). Mortality after TAVI has been associated with severe Paravalvular Aortic Regurgitation (PAR). PAR occurs when the frame of the TAVI device does not make an effective seal against the internal surface of the aortic root, allowing blood to flow backwards about the valve. PAR is common in patients and has been reported to some degree in as much as 76% of cases. Severe PAR (grade 3 or 4) has been reported in approximately 17% of TAVI patients resulting in post-procedural mortality increases from 6.7% to 16.5%. TAVI devices, like SVR devices, are circular in cross-section as the aortic root is often considered to be approximately circular in shape. In reality, however, the aortic root is often non-circular. The ascending aorta, aortic sino tubular junction, aortic annulus and left ventricular outflow tract have an average ellipticity ratio of 1.07, 1.09, 1.29, and 1.49 respectively. An elliptical aortic root does not severely affect SVR, as the leaflets are completely removed during the surgical procedure. However, an elliptical aortic root can inhibit the ability of the circular Balloon-Expandable (BE) TAVI devices to conform to the interior of the aortic root wall, which increases the risk of PAR. Self-Expanding (SE) TAVI devices are considered better at conforming to elliptical aortic roots, however the valve leaflets were not designed for elliptical function, furthermore the incidence of PAR is greater in SE devices than BE devices (19.8% vs. 12.2% respectively). If a patient’s aortic root is too severely elliptical, they will not be suitable for TAVI, narrowing the treatment options to SVR. It therefore follows that in order to increase the population who can undergo TAVI, and reduce the risk associated with TAVI, non-circular devices should be developed. Computational simulations were employed to further advance our understanding of non-circular TAVI devices. Radial stiffness of the TAVI devices in multiple directions, frame bending stiffness and resistance to balloon induced expansion are all computationally simulated. Finally, a simulation has been developed that demonstrates the expansion of TAVI devices into a non-circular patient specific aortic root model in order to assess the alterations in deployment dynamics, PAR and the stresses induced in the aortic root.

Keywords: tavi, tavr, fea, par, fem

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Authors: S. Ben Fredj, H. Ghali, M. Ben Rejeb, S. Layouni, S. Khefacha, L. Dhidah, H. Said

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Background: The Intensive Care Unit (ICU) provides continuous care and uses a high level of treatment technologies. Although developed country hospitals allocate only 5–10% of beds in critical care areas, approximately 20% of nosocomial infections (NI) occur among patients treated in ICUs. Whereas in the developing countries the situation is still less accurate. The aim of our study is to assess mortality rates in ICUs and to determine its predictive factors. Methods: We carried out a nested case-control study in a 630-beds public tertiary care hospital in Eastern Tunisia. We included in the study all patients hospitalized for more than two days in the surgical or medical ICU during the entire period of the surveillance. Cases were patients who died before ICU discharge, whereas controls were patients who survived to discharge. NIs were diagnosed according to the definitions of ‘Comité Technique des Infections Nosocomiales et les Infections Liées aux Soins’ (CTINLIS, France). Data collection was based on the protocol of Rea-RAISIN 2009 of the National Institute for Health Watch (InVS, France). Results: Overall, 301 patients were enrolled from medical and surgical ICUs. The mean age was 44.8 ± 21.3 years. The crude ICU mortality rate was 20.6% (62/301). It was 35.8% for patients who acquired at least one NI during their stay in ICU and 16.2% for those without any NI, yielding an overall crude excess mortality rate of 19.6% (OR= 2.9, 95% CI, 1.6 to 5.3). The population-attributable fraction due to ICU-NI in patients who died before ICU discharge was 23.46% (95% CI, 13.43%–29.04%). Overall, 62 case-patients were compared to 239 control patients for the final analysis. Case patients and control patients differed by age (p=0,003), simplified acute physiology score II (p < 10-3), NI (p < 10-3), nosocomial pneumonia (p=0.008), infection upon admission (p=0.002), immunosuppression (p=0.006), days of intubation (p < 10-3), tracheostomy (p=0.004), days with urinary catheterization (p < 10-3), days with CVC ( p=0.03), and length of stay in ICU (p=0.003). Multivariate analysis demonstrated 3 factors: age older than 65 years (OR, 5.78 [95% CI, 2.03-16.05] p=0.001), duration of intubation 1-10 days (OR, 6.82 [95% CI, [1.90-24.45] p=0.003), duration of intubation > 10 days (OR, 11.11 [95% CI, [2.85-43.28] p=0.001), duration of CVC 1-7 days (OR, 6.85[95% CI, [1.71-27.45] p=0.007) and duration of CVC > 7 days (OR, 5.55[95% CI, [1.70-18.04] p=0.004). Conclusion: While surveillance provides important baseline data, successful trials with more active intervention protocols, adopting multimodal approach for the prevention of nosocomial infection incited us to think about the feasibility of similar trial in our context. Therefore, the implementation of an efficient infection control strategy is a crucial step to improve the quality of care.

Keywords: intensive care unit, mortality, nosocomial infection, risk factors

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Authors: Alexander Zotov, Ilkin Osmanov, Emil Sakharov, Oleg Shelest, Aleksander Troitskiy, Robert Khabazov

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Objective: Thoracoscopic surgical ablation of atrial fibrillation (AF) includes two technologies in performing of operation. 1st strategy used is the AtriCure device (bipolar, nonirrigated, non clamping), 2nd strategy is- the Medtronic device (bipolar, irrigated, clamping). The study presents a comparative analysis of clinical outcomes of two strategies in thoracoscopic ablation of AF using AtriCure vs. Medtronic devices. Methods: In 2 center study, 123 patients underwent thoracoscopic ablation of AF for the period from 2016 to 2020. Patients were divided into two groups. The first group is represented by patients who applied the AtriCure device (N=63), and the second group is - the Medtronic device (N=60), respectively. Patients were comparable in age, gender, and initial severity of the condition. Among the patients, in group 1 were 65% males with a median age of 57 years, while in group 2 – 75% and 60 years, respectively. Group 1 included patients with paroxysmal form -14,3%, persistent form - 68,3%, long-standing persistent form – 17,5%, group 2 – 13,3%, 13,3% and 73,3% respectively. Median ejection fraction and indexed left atrial volume amounted in group 1 – 63% and 40,6 ml/m2, in group 2 - 56% and 40,5 ml/m2. In addition, group 1 consisted of 39,7% patients with chronic heart failure (NYHA Class II) and 4,8% with chronic heart failure (NYHA Class III), when in group 2 – 45% and 6,7%, respectively. Follow-up consisted of laboratory tests, chest Х-ray, ECG, 24-hour Holter monitor, and cardiopulmonary exercise test. Duration of freedom from AF, distant mortality rate, and prevalence of cerebrovascular events were compared between the two groups. Results: Exit block was achieved in all patients. According to the Clavien-Dindo classification of surgical complications fraction of adverse events was 14,3% and 16,7% (1st group and 2nd group, respectively). Mean follow-up period in the 1st group was 50,4 (31,8; 64,8) months, in 2nd group - 30,5 (14,1; 37,5) months (P=0,0001). In group 1 - total freedom of AF was in 73,3% of patients, among which 25% had additional antiarrhythmic drugs (AADs) therapy or catheter ablation (CA), in group 2 – 90% and 18,3%, respectively (for total freedom of AF P<0,02). At follow-up, the distant mortality rate in the 1st group was – 4,8%, and in the 2nd – no fatal events. Prevalence of cerebrovascular events was higher in the 1st group than in the 2nd (6,7% vs. 1,7% respectively). Conclusions: Despite the relatively shorter follow-up of the 2nd group in the study, applying the strategy using the Medtronic device showed quite encouraging results. Further research is needed to evaluate the effectiveness of this strategy in the long-term period.

Keywords: atrial fibrillation, clamping, ablation, thoracoscopic surgery

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Authors: Geliashvili T. M., Tyulyandina A. S., Valiev A. K., Kononets P. V., Kharatishvili T. K., Salkov A. G., Pronin A. I., Gadzhieva E. H., Parnas A. V., Ilyakov V. S.

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Aim/Introduction: Metastasis (Mts) to the sternum, while extremely rare in differentiated thyroid cancer (DTC) (1), requires a personalized, multidisciplinary treatment approach. In aggressively growing Mts to the sternum, which rapidly become unresectable, a comprehensive therapeutic and diagnostic approach is particularly important. Materials and methods: We present a clinical case of solitary Mts to the sternum as first manifestation of a papillary thyroid microcarcinoma in a 55-year-old man. Results: 18F-FDG PET/CT after thyroidectomy confirmed the solitary Mts to the sternum with extremely high FDG uptake (SUVmax=71,1), which predicted its radioiodine-refractory (RIR). Due to close attachment to the mediastinum and rapid growth, Mts was considered unresectable. During the next three months, the patient received targeted therapy with the tyrosine kinase inhibitor (TKI) Lenvatinib 24 mg per day. 1st course of radioiodine therapy (RIT) 6 GBq was also performed, the results of which confirmed the RIR of the tumor process. As a result of systemic therapy (targeted therapy combined with RIT and suppressive hormone therapy with L-thyroxine), there was a significant biochemical response (decrease of serum thyroglobulin level from 50,000 ng/ml to 550 ng/ml) and a partial response with decrease of tumor size (from 80x69x123 mm to 65x50x112 mm) and decrease of FDG accumulation (SUVmax from 71.1 to 63). All of this made possible to perform surgical treatment of Mts - sternal extirpation with its replacement by an individual titanium implant. At the control examination, the stimulated thyroglobulin level was only 134 ng/ml, and PET/CT revealed postoperative areas of 18F-FDG metabolism in the removed sternal Mts. Also, 18F-FDG PET/CT in the early (metabolic) stage revealed two new bone Mts (in the area of L3 SUVmax=17,32 and right iliac bone SUVmax=13,73), which, as well as the removed sternal Mts, appeared to be RIRs at the 2nd course of RIT 6 GBq. Subsequently, on 02.2022, external beam radiation therapy (EBRT) was performed on the newly identified oligometastatic bone foci. At present, the patient is under dynamic monitoring and in the process of suppressive hormone therapy with L-thyroxine. Conclusion: Thus, only due to the early prescription of targeted TKI therapy was it possible to perform surgical resection of Mts to the sternum, thereby improve the patient's quality of life and preserve the possibility of radical treatment in case of oligometastatic disease progression.

Keywords: differentiated thyroid cancer, metastasis to the sternum, radioiodine therapy, radioiodine-refractory cancer, targeted therapy, lenvatinib

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Authors: I. T. Asowata, A. S. Akinwumiju

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The enrichment of potentially harmful elements (PHEs) in stream sediments (SS) and floodplain soils (FS) poses great environmental hazards to water bodies and other parts of the ecosystem. The aim of this research was to assess the distribution pattern of selected PHEs (Cu, Pb, Zn, Co, Mn, As, Cd, V, Cr, Ni, Th, Sr, and La) in SS of selected rivers that drain Ile-Ife area and their adjacent FS, to ascertain the pollution status of these elements in the study area. 60 samples (40 SS and 20 FS) were purposely collected for this study; the samples were air-dried at room temperature, disaggregated, sieved with > 63 µm and digested with modified aqua reqia (1:1:1 HCl:HNO₃:H₂O) and were analysed with ultra-trace inductively coupled plasma mass spectrometry method (ICP-ES). The geochemical results showed decreasing trend of average contents of PHEs studied Mn > Zn > V > Cr > Pb > La > Sr > Cu > Ni > Co > Th > As > Cd for both SS and FS. Floodplain topsoil in ppm, Cu range from 10.0-180.0; mean, 71.1, Pb, 17.1-255.0; 93.5 and Zn, 83.0-3122.2; 826.0. Also, floodplain sub-soils, Cu range from 30.0-203.1; mean of 76.6, Pb, 16.0-214.0; 77.9 and Zn, 59.1-2351.0; 622.3. Similarly, SS results for Cu, 22.1-257.0; 70.3, Pb, 15.0-172.0; 67.3 and Zn, 65.0-1285.0; 357.8, among other PHEs, suggesting significant level of PHEs enrichment in the studied geo media. Elemental association showed positive and/or negative correlation among the PHEs and also showed different sources of metal enrichment to be largely anthropogenic with some geogenic. Geoaccumulation and metal ratio indexes indicated that FS and SS studied have received significant PHEs of between moderately to strongly polluted, which implies significant environmental implications in the study area.

Keywords: aqua regia, enrichment, GIS, Ile-Ife, potentially harmful elements

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Authors: N. H. D. P. Fonseka, I. H. Rajapakse, A. S. Dissanayake

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Background: Problem drinking, namely alcohol dependence (AD) and alcohol abuse (AA) are associated with major medical, social and economic adverse consequences. Problem drinking behavior is noted among those admitted to hospitals due to alcohol-related medical/surgical complaints as well as those with unrelated complaints. Literature shows an association between alcohol consumption and depression. Aims of this study were to determine the frequency of problem drinking and depression among males with a history of alcohol consumption tertiary care setting in Southern Sri Lanka. Method: Two-hundred male patients who consumed alcohol, receiving care in medical and surgical wards in Teaching Hospital Galle, were assessed. A validated J12 questionnaire of the Mini International Neuropsychiatric Interview was administered to determine frequency AA and AD. A validated PHQ 9 questionnaire to determine the prevalence and severity of depression. Results: Sixty-three participants (31%) had problem drinking. Of them, 61% had AD, and 39% had AA. Depression was noted in 39 (19%) subjects. In those who reported alcohol consumption not amounting to problem drinking, depression was noted in 23 (16%) participants. Mild depression was seen in 17, moderate in five and moderately severe in one. Among those who had problem drinking, 16 (25%) had depression. Mild depression was seen in four, moderate in seven, moderately severe in three and severe in two. Conclusions: A high proportion alcohol users had problem drinking. Adverse consequences associated with problem drinking places a major strain on the health system especially in a low resource setting where healthcare spending is limited and alcohol cessation support services are not well organised. Thus alcohol consumption and problem drinking behaviour need to be inquired into all medical consultations. Community prevalence of depression in Sri Lanka is approximately 10%. Depression among those consuming alcohol was two times higher compared to the general population. The rates of depression among those with problem drinking were especially high being 2.5 times more common than in the general population. A substantial proportion of these patients with depression had moderately severe or severe depression. When depression coexists with problem drinking, it may increase the tendency to consume alcohol as well as act as a barrier to the success of alcohol cessation interventions. Thus screening all patients who consume alcohol for depression, especially those who are problem drinkers becomes an important step in their clinical evaluation. In addition, in view of the high prevalence of problem drinking and coexistent depression, the need to organize a structured alcohol cessation support service in Sri Lanka as well as the need for increasing access to psychological evaluation and treatment of those with problem drinking are highlighted.

Keywords: alcohol abuse, alcohol, depression, problem drinking

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Authors: Taleb Lotfi, Benarbia Maheidine, Allam Hamza, Boutira Fatima, Boukerche Abdelbaki

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Introduction and purpose of the study: This is a retrospective single-center study with an analytical aim to determine the prognostic factors for relapse in patients treated with radiotherapy after total laryngectomy with lymph node dissection for laryngeal cancer at the Emir Abdelkader cancer center in Oran (Algeria). Material and methods: During the study period from January 2014 to December 2018, eighty-nine patients (n=89) with squamous cell carcinoma of the larynx were treated with postoperative radiotherapy. Relapse-free survival was studied in the univariate analysis according to pre-treatment criteria using Kaplan-Meier survival curves. We performed a univariate analysis to identify relapse factors. Statistically significant factors have been studied in the multifactorial analysis according to the Cox model. Results and statistical analysis: The average age was 62.7 years (40-86 years). It was a squamous cell carcinoma in all cases. Postoperatively, the tumor was classified as pT3 and pT4 in 93.3% of patients. Histological lymph node involvement was found in 36 cases (40.4%), with capsule rupture in 39% of cases, while the limits of surgical excision were microscopically infiltrated in 11 patients (12.3%). Chemotherapy concomitant with radiotherapy was used in 67.4% of patients. With a median follow-up of 57 months (23 to 104 months), the probabilities of relapse-free survival and five-year overall survival are 71.2% and 72.4%, respectively. The factors correlated with a high risk of relapse were locally advanced tumor stage pT4 (p=0.001), tumor site in case of subglottic extension (p=0.0003), infiltrated surgical limits R1 (p=0.001), l lymph node involvement (p=0.002), particularly in the event of lymph node capsular rupture (p=0.0003) as well as the time between surgery and adjuvant radiotherapy (p=0.001). However, in the subgroup analysis, the major prognostic factors for disease-free survival were subglottic tumor extension (p=0.001) and time from surgery to adjuvant radiotherapy (p=0.005). Conclusion: Combined surgery and postoperative radiation therapy are effective treatment modalities in the management of laryngeal cancer. Close cooperation of the entire cervicofacial oncology team is essential, expressed during a multidisciplinary consultation meeting, with the need to respect the time between surgery and radiotherapy.

Keywords: laryngeal cancer, laryngectomy, postoperative radiotherapy, survival

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Authors: Abd-Alrahman Embaby, Ayman Abu Halawa, Medhat Ramadan

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The infiltrated water into the subsurface activates expansive soil in localized manner, leading to the differential heaving and destructive of the construction. The Watershed Modeling System (WMS) and Hydrologic Engineering Center (HEC-1) are used to delineate and identify the drainage system and basin morphometry in Tabuk area, where flash floods and accumulation of water may take place. Eight drainage basins effect on Tabuk city. Three of them are expected to be high. The flash floods and surface runoff behavior in these basins are important for any protection projects. It was found that the risky areas that contain Tabuk shale could be expanded when exposed to flash floods and/or surface runoff. The resident neighborhoods in the middle of Tabuk city and affected by surface runoff of the tributaries of the basin of Wadi Abu Nishayfah, Na'am and Atanah outlet, represent high-risk zones. These high-risk neighborhoods are Al Qadsiyah, Al Maseif, Arrwdah, Al Nakhil and Al Rajhi. It can be avoided new constructions on these districts. The low or very low-risk zones include the western and the eastern districts. The western side of the city is lying in the upstream of the small basin. It is suitable for a future urban extension. The direction of surface runoff flow or storm water drain discharge should be away from Tabuk city. The quicker the water can flow out, the better it is.

Keywords: digital elevation model (DEM), flash floods, Saudi Arabia, Tabuk City, watershed modeling system (WMS)

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Authors: Atmaja Patel

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Since the development of lasers in 1951, the first medical application was reported by Goldman in 1962. In 1960, T.H. Maiman produced the first Ruby laser and was used in cardiovascular surgery by McGuff in 1963. After a long time of investigations and new developments in laser technology first clinical applications were performed by Choy and Ginsburg in 1983. Introduction of the first true dental laser was in 1989. This paper is to highlight the various treatments and prevention of periodontal diseases. Lasers have become more predictable and effective form of treatment for periodontal diseases. The advantages of lasers include reduced use of anaesthesia, coagulation that yields a dry surgical field and hence better visibility, reduced need of sutures, minimal swelling and scarring, less pain and medication, faster healing and increased patient acceptance.

Keywords: lasers, periodontal surgery, diode laser, healing

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Authors: Noreen Pulte

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Prior to the 'Back to Sleep' Campaign in 1992, 1 of every 300 infants seen by Advanced Practice Providers had plagiocephaly. Insufficient attention is given to plagiocephaly and brachycephaly diagnoses in practice and pediatric education. In this talk, Nurse Practitioners and Pediatric Providers will be able to: (1) identify red flags associated with head shape abnormalities, (2) learn techniques they can teach parents to prevent head shape abnormalities, and (3) differentiate between plagiocephaly, brachycephaly, and craniosynostosis. The presenter is a Primary Care Pediatric Nurse Practitioner at Ann & Robert H. Lurie Children's Hospital of Chicago and the primary provider for its head shape abnormality clinics. She will help participants translate key information obtained from birth history, review of systems, and developmental history to understand risk factors for head shape abnormalities and progression of deformities. Synostotic and non-synostotic head shapes will be explained to help participants differentiate plagiocephaly and brachycephaly from synostotic head shapes. This knowledge is critical for the prompt referral of infants with craniosynostosis for surgical evaluation and correction. Rapid referral for craniosynostosis can possibly direct the patient to a minimally invasive surgical procedure versus a craniectomy. As for plagiocephaly and brachycephaly, this timely referral can also aid in a physical therapy referral if necessitated, which treats torticollis and aids in improving head shape. A well-timed referral to a head shape clinic can possibly eliminate the need for a helmet and/or minimize the time in a helmet. Practitioners will learn the importance of obtaining head measurements using calipers. The presenter will explain head calculations and how the calculations are interpreted to determine the severity of the head shape abnormalities. Severity defines the treatment plan. Participants will learn when to refer patients to a head shape abnormality clinic and techniques they should teach parents to perform while waiting for the referral appointment. The purpose, mechanics, and logistics of helmet therapy, including optimal time to initiate helmet therapy, recommended helmet wear-time, and tips for helmet therapy compliance, will be described. Case scenarios will be incorporated into the presenter's presentation to support learning. The salient points of the case studies will be explained and discussed. Practitioners will be able to immediately translate the knowledge and skills gained in this presentation into their clinical practice.

Keywords: plagiocephaly, brachycephaly, craniosynostosis, red flags

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Authors: Ebele V. Okoli, Emmanuel Nwobi, Dozie Ezechukwu, Ijeoma Itanyi

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One in seven people worldwide suffer from a disability. 80% of people with disabilities live in developing countries. Negative attitudes and misconceptions among health-care providers constitute barri¬ers to optimal health care for people with disabilities. This underscores the relevance of a study of the attitude of Nigerian medical students towards disability and their willingness to work in the disability sector. This was a descriptive cross-sectional study conducted among 254 penultimate and final year medical students of a university in southeastern Nigeria. The mean age of the students was 24.8 ± 3.12 years. Majority of the students were male (75.2%), single (96.9%), of the Igbo tribe (86.6%), Christian (97.6%) and grew up in urban areas (68.1%). Results indicated that the medical students had a predominantly positive attitude towards people with disability as 73.8% had a positive attitude and mean attitude score was 67.03 ± 0.14 (positive attitude = 61 – 120, negative attitude = 0 - 60). Chi-square analysis did not show any significant effect of demographic and social factors on the students’ attitude towards People with Disabilities. The students were mostly willing to work in areas that address the challenges of people with disability (70.4%) but a greater proportion had never heard about Disability Studies (67.5%). About a third of the students (33.2%) would like to travel abroad to practice in the disability sector. Conclusions: The students generally had a positive attitude towards people with disability and a greater percentage were willing to work in the disability sector in their future career. About two-thirds had however, never heard about disability studies. There was some potential for brain drain among the students as a third of the population intended to practice abroad on graduation.

Keywords: attitudes, career interest, disability, medical students

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Authors: Yousef Alwashahi, Ahmed Almoqbali, Mayar Albahrani, Asma Alajmi

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We report a rare case of a 49-year-old Omani woman who is a known case of primary anti-phospholipid syndrome, glucose-6-phosphate dehydrogenase deficiency, and iron deficiency anaemia. During cannulation, she was found to develop bulla that progressed to ulcerations. With chronicity and recurrent abscess formation that usually increase after surgical intervention, a pathergy phenomenon was postulated. High suspicion of pyoderma gangrenosum was considered. Fortunately, the rapid progression of the disease was slowed down with corticosteroids, cyclosporin, and biological agents.

Keywords: anti-phospholipid syndrome, pyoderma gangrenosum, bullous pyoderma gangrenosum, pathergy, pathergy phenomenon

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Authors: Doaa H. Elgohary, Tamer F. Khalifa, Mona M. Salem, M. A. Saad, Ehab Haider Sherazy

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Textiles have conquered new areas over the past three decades, including agriculture, transportation, filtration, military, and medicine. The use of textiles in the medical field has increased significantly in recent years and covers almost everything. Medical textiles represent a huge market as they are widely used not only in hospitals, hygiene, and healthcare but also in hotels and other environments where hygiene is required. However, not all fibers are suitable for the manufacture of medical textile products. Some special properties are required for the manufactured materials, e.g. Strength, elasticity, spinnability, etc. In addition to the usual properties of medical fibers, non-toxicity, sterilizability, biocompatibility, biodegradability, good absorbability, softness, and freedom from additives, etc., desirable properties include impurities. Stitching is one of the most common practices in the medical field. as it is a biomaterial device, either natural or synthetic, used to connect blood vessels and connect tissues. In addition to being very strong, suture material should easily dissolve in bodily fluids and lose strength as the tissue gains strength. In this work, a study to select the most used materials for sutures, it was found that silk, VICRYL and polypropylene were the most used materials in varying numbers. The research involved the analysis of 36 samples from three different materials (mostly commonly used), the tests were carried out on 36 imported samples for four different companies. Each company supplied three different materials (silk, VICRYL and polypropylene) with three different gauges (4, 3.5 and 3 metric). The results of the study were tabulated, presented, and discussed. Practical statistical science serves to support the practical analysis of experimental work products and the various relationships between variables to achieve the best sampling performance with the functional purpose generated for it. Analysis of the imported sutures shows that VICRYL sutures had the highest tensile strength, toughness, knot tensile strength and knot toughness, followed by polypropylene and silk. As yarn counts, weight and diameter increase, its tensile strength and toughness increase while its elongation and knot tension decrease. The multifilament yarn construction (silk and VICRYL) scores higher compared to the monofilament construction (polypropylene), resulting in increases in tenacity, toughness, knot tensile strength and knot toughness.

Keywords: biodegradable yarns, braided sutures, irritation, knot tying, medical textiles, surgical sutures, wound healing

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Authors: Ya-Chu May Tsai, Ibrahim Yacoub, Eoin Casey

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The Australian and New Zealand College of Anaesthetists (ANZCA) advises that smoking should not be permitted within 12 hours of surgery. There is little information in the medical literature regarding patients awareness of perioperative smoking cessation recommendations nor their appreciation of how smoking might negatively impact their perioperative course. The aim of the study is to assess the prevalence of current smokers presenting to Werribee Mercy Hospital (WMH) and to evaluate if pre-operative provision of both written and verbal pre-operative advice was, 1: Effective in improving patient awareness of the benefits of pre-operative smoking cessation, 2: Associated with an increase in the number of elective surgical patients who stop smoking at least 12 hours pre-operatively. Methods: The initial survey included all patients who presented to WMH for elective surgical procedures from 19 – 30 September 2016 using a standardized questionnaire focused on patients’ smoking history and their awareness of smoking cessation preoperatively. The intervention consisted of a standard pre-operative phone call to all patients advising them of the increased perioperative risks associated with smoking, and advised patients to cease 12 hours prior. In addition, written information on smoking cessation strategies were sent out in mail at least 1 week prior to planned procedure date to all patients. Questionnaire-based study after the intervention was conducted on day of elective procedure from 10 – 21 October 2016 inclusive. Primary outcomes measured were patient’s awareness of smoking cessation and proportion of smokers who quit >12 hours, considered a clinically meaning duration to reduce anaesthetics complications. Comparison of pre and post intervention results were made using SPSS 21.0. Results: In the pre-intervention group (n=156), 36 (22.4%) patients were current smokers, 46 were ex-smokers (29.5%) and 74 were non-smokers (48.1%). Of the smokers, 12 (33%) reported having been informed of smoking cessation prior to operation and 8 (22%) were aware of increased intra- and perioperative adverse events associated with smoking. In the post-intervention group n= 177, 38 (21.5%) patients were current smokers, 39 were ex-smokers (22.0%) and 100 were non-smokers (56.5%). Of the smokers, 32 (88.9%) reported having been informed of smoking cessation prior to operation and 35 (97.2%) reported being aware of increased intra- and perioperative adverse events associated with smoking. The median time since last smoke in the pre-intervention group was 5.5 hours (Q1-Q3 = 2-14) compared with 13 hours (Q1-Q3 = 5-24) in post intervention group. Amongst the smokers, smoking cessation at least 12 hours prior to surgery significantly increased from 27.8% pre-intervention to 52.6% post intervention (P=0.03). Conclusion: A standard preoperative phone call and written instruction on smoking cessation guidelines at time of waitlist placement increase preoperative smoking cessation rates by almost 2-fold.

Keywords: anaesthesia, audit, perioperative medicine, smoking cessation

Procedia PDF Downloads 306

Authors: M. Abbasi

Abstract:

A spillway structure is used to pass excess water and floods from upstream or upstream to downstream or tributary. The spillway is considered one of the most key members of the dam, and the failure of many dams is attributed to the inefficiency of their spillway. Weirs should be selected as strong, reliable and high-performance structures, and weirs should be ready for use in all conditions and able to drain the flood so that we do not witness many casualties and financial losses when a flood occurs. The purpose of this study is to simulate the flow pattern passing over the peak spillway in order to optimize and adjust the height of the spillway walls. In this research, the effect of the shape of the side wings on the flow pattern over the peak spillways of the Gotvand reservoir dam was simulated and modelled using Flow3D software. In this research, side wings with rounded walls with six different approach angles were used. In addition, the different value of H/Hd was used to check the effect of the tank head. The results showed that with the constant H/Hd ratio and the increase of the approach angle of the side wing, the flow depth first decreases and then increases. These changes were the opposite regarding the depth average speed of the flow and the depth average concentration of the air entering the flow. At the same time, with the constant angle of approach of the side wing and with the increase of H/Hd ratio, the flow depth increases. In general, a correct understanding of the operation of overflows and a correct design can significantly reduce construction costs and solve flooding problems.

Keywords: effect of the shape, gotvand reservoir dam, narrowing coefficients, supports of the gates

Procedia PDF Downloads 66

Authors: Laurence Weinberg, Dominic Walpole, Dong-Kyu Lee, Michael D’Silva, Jian W. Chan, Lachlan F. Miles, Bradley Carp, Adam Wells, Tuck S. Ngun, Siven Seevanayagam, George Matalanis, Ziauddin Ansari, Rinaldo Bellomo, Michael Yii

Abstract:

Background: There have been multiple recent advancements in the selection, optimization and management of cardiac surgical patients. However, there is limited data regarding the outcomes of nonagenarians undergoing cardiac surgery, despite this vulnerable cohort increasingly receiving these interventions. This study describes the patient characteristics, management and outcomes of a group of nonagenarians undergoing cardiac surgery in the context of contemporary peri-operative care. Methods: A retrospective observational study was conducted of patients 90 to 99 years of age (i.e., nonagenarians) who had undergone cardiac surgery requiring a classic median sternotomy (i.e., open-heart surgery). All operative indications were included. Patients who underwent minimally invasive surgery, transcatheter aortic valve implantation and thoracic aorta surgery were excluded. Data were collected from four hospitals in Victoria, Australia, over an 8-year period (January 2012 – December 2019). The primary objective was to assess six-month mortality in nonagenarians undergoing open-heart surgery and to evaluate the incidence and severity of postoperative complications using the Clavien-Dindo classification system. The secondary objective was to provide a detailed description of the characteristics and peri-operative management of this group. Results: A total of 12,358 adult patients underwent cardiac surgery at the study centers during the observation period, of whom 18 nonagenarians (0.15%) fulfilled the inclusion criteria. The median (IQR) [min-max] age was 91 years (90.0:91.8) [90-94] and 14 patients (78%) were men. Cardiovascular comorbidities, polypharmacy and frailty, were common. The median (IQR) predicted in-hospital mortality by EuroSCORE II was 6.1% (4.1-14.5). All patients were optimized preoperatively by a multidisciplinary team of surgeons, cardiologists, geriatricians and anesthetists. All index surgeries were performed on cardiopulmonary bypass. Isolated coronary artery bypass grafting (CABG) and CABG with aortic valve replacement were the most common surgeries being performed in four and five patients, respectively. Half the study group underwent surgery involving two or more major procedures (e.g. CABG and valve replacement). Surgery was undertaken emergently in 44% of patients. All patients except one experienced at least one postoperative complication. The most common complications were acute kidney injury (72%), new atrial fibrillation (44%) and delirium (39%). The highest Clavien-Dindo complication grade was IIIb occurring once each in three patients. Clavien-Dindo grade IIIa complications occurred in only one patient. The median (IQR) postoperative length of stay was 11.6 days (9.8:17.6). One patient was discharged home and all others to an inpatient rehabilitation facility. Three patients had an unplanned readmission within 30 days of discharge. All patients had follow-up to at least six months after surgery and mortality over this period was zero. The median (IQR) duration of follow-up was 11.3 months (6.0:26.4) and there were no cases of mortality observed within the available follow-up records. Conclusion: In this group of nonagenarians undergoing cardiac surgery, postoperative six-month mortality was zero. Complications were common but generally of low severity. These findings support carefully selected nonagenarian patients being offered cardiac surgery in the context of contemporary, multidisciplinary perioperative care. Further, studies are needed to assess longer-term mortality and functional and quality of life outcomes in this vulnerable surgical cohort.

Keywords: cardiac surgery, mortality, nonagenarians, postoperative complications

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Authors: Anis Al-Yakhiri

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Introduction: The World Health Organization (WHO) classifies malignant epithelial thyroid tumors into four major groups (papillary, follicular, medullar and undifferentiated) . Papillary thyroid carcinoma (PTC) is the most common type, for about eight out of ten thyroid cancers belong to this histological type. Radioactive iodine (RAI) is considered effective for patients with total or nearly total thyroidectomy, but the beneficial effects of RAI are still controversial. War conditions forced us to study alternative methods of using radioactive iodine in the treatment of patients with PTC. Material and methods: Between January 2014 and June 2021, in Al-Yakhiri hospital, 57 Total Thyroidectomy with Radical BilateralNeckDissection (RBND) were performed, 50 for malignant disease,7 for false positive cytology.RBND involves surgical clearance of Levels II-VI. Mean age was 40.7 years old and 92% of the patients were female. 7(14%) patients had hypothyroidism which required preoperative thyroid hormone treatment. The Thyroid Stimulating Hormone- Suppression Therapy (TSH-ST) immediately started after RBND for mostpatients on the first day. It consisted in reducing the level of TSH< 0.1 mIU/L. Results: The Apron flap was used on most operations (40)80% and with lateral extensions had 10(20%). RBND involves surgical clearance of Levels II-VI performed in all operated patients, besides that, 4(8%) of them had resection of sternocleidomastoid muscle (SCM) and accessory nerve (XIn) and internal jugular vein (IJV) withclearance of Levels IB. The PTC was the most common 80.9% (38 patients from 47)by histopathological report. and 4(8%) patients of 50 had resection of sternocleidomastoid muscle (SCM) and accessory nerve (XIn) and internal jugular vein (IJV). The postoperative mortality rate not observed (0%). The postoperative morbidity rate was 22.8% (n =13).Seroma(8.7%),Hypocalcimia(7%), Wound infection(5.3%), Bleeding(1.8%). To suppress TSH and growth of any residual thyroid theTSH-ST (levothyroxine150 – 600mcg)was performed in all patients 57(100%) on the first day afterRBND. We tracked the results of treatment for two years in 30 patients with PTC, only 3 of them received radioactive iodine abroad. Biennial Recurrence rate for PTC appeared in one woman (2%), who had RAI postoperatively in the form of neck lymph nodes metastasis. Conclusion: For patients with PTC, thyroidectomy plus prophylacticRBND is a safe and efficient procedure and it results in lower recurrence rate. Postoperative treatment with exogenous thyroid hormone in doses sufficient to suppress TSH (not less than 150mcg), decreases incidence of recurrence. Total Thyroidectomy with RBND followed by TSH-ST, in our opinion, applicable optimal treatment scheme care for this patient population.

Keywords: thyroid cancer, Yemen war, absence of radioactive iodine, neck dissection, surgery results

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Authors: Chandra Shekhar Majumder, Orin Sultana Jamie

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Background: Dacryocystorhinostomy (DCR) has been a widely accepted surgical intervention for nasolacrimal duct obstructions. Some previous studies demonstrated the potential benefits of the peroperative application of agents like Mitomycin-C (MMC) with DCR to improve surgical outcomes. Relevant studies are rare in Bangladesh, and there are controversies about the dose, duration of MMC, and outcome. Therefore, the present study aimed to investigate the comparative efficacy of DCR with and without MMC in a tertiary hospital in Bangladesh. Objective: The study aims to determine the outcome of a dacryocystorhinostomy with preoperative local use of mitomycin–C. Methods: An analytical study was conducted in the Department of Ophthalmology, Sir Salimullah Medical College & Mitford Hospital, Dhaka, from January 2023 to September 2023. Seventy patients who were admitted for DCR operation were included according to the inclusion and exclusion criteria. Patients were divided into two groups: those who underwent DCR with peroperative administration of 0.2 mg/ml Mitomycin-C for 5 minutes (Group I) and those who underwent DCR alone (Group II). All patients were subjected to detailed history taking, clinical examination, and relevant investigations. All patients underwent DCR according to standard guidelines and ensured the highest peroperative and postoperative care. Then, patients were followed up at 7th POD, 1-month POD, 3 months POD, and 6 months POD to observe the success rate between the two groups by assessing tearing condition, irrigation, height of tear meniscus, and FDDT- test. Data was recorded using a pre-structured questionnaire, and collected data were analyzed using SPSS 23. Results: The mean age of the study patients was 42.17±6.7 (SD) years and 42.29±7.1 (SD) years in Groups I and II, respectively, with no significant difference (p=0.945). At the 6th month’s follow-up, group I patients were observed with 94.3% frequency of symptom-free, 85.6% patency of lacrimal drainage system, 68.6% had tear meniscus <0.1mm and 88.6% had positive Fluorescence Dye Disappearance Test (FDDT test). In group II, 91.4% were symptom-free, 68.6% showed patency, 57.1% had a height of tear meniscus < 0.1 mm, and 85.6% had FDDT test positive. But no statistically significant difference was observed (p<.05). Conclusion: The use of Mitomycin-C preoperatively during DCR offers better postoperative outcomes, particularly in maintaining patency and achieving symptom resolution with more FDDT test positive and improvement of tear meniscus in the MMC group than the control group. However, this study didn’t demonstrate a statistically significant difference between the two groups. Further research with larger sample sizes and longer follow-up periods would be beneficial to corroborate these findings.

Keywords: dacryocystorhinostomy, mitomycin-c, dacryocystitis, nasolacrimal duct obstruction

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Authors: Spencer Liu, William Chan, Marlena Komatz, Tommy Ramos, Mark Trentalange, Faye Rim, Dae Kim, Mary Kelly, Samuel Schuessler, Roberta Stack, Justas Lauzadis, Kathryn DelPizzo, Seth Waldman, Alexandra Sideris

Abstract:

Background & Significance: The increasing prevalence of cannabis use in the United States has important safety considerations in the perioperative setting, as chronic or heavy preoperative cannabis use may increase the risk of intraoperative complications, postoperative nausea and vomiting (PONV), increased postoperative pain levels, and acute side effects associated with cannabis use cessation. In this retrospective chart review study, we sought to determine the prevalence of self-reported cannabis use in the past 5-years at a single institution in New York City. We hypothesized that there is an increasing prevalence of preoperative self-reported cannabis use among adult and adolescent patients undergoing orthopedic surgery. Methods: After IRB approval for this retrospective study, surgical cases performed on patients 12 years of age and older at the hospital’s main campus and two ambulatory surgery centers between January 1st, 2018, and December 31st, 2023, with preoperatively self-disclosed cannabis use entered in the social history intake form were identified using the tool SlicerDicer in Epic. Case and patient characteristics were extracted, and trends in utilization over time were assessed by the Cochran-Armitage trend test. Results: Overall, the prevalence of self-reported cannabis use increased from 6.6% in 2018 to 10.6% in 2023. By age group, the prevalence of self-reported cannabis use among adolescents remained consistently low (2018: 2.6%, 2023: 2.6%) but increased with significant evidence for a linear trend (p < 0.05) within every adult age group. Among adults, patients who were 18-24 years old (2018: 18%, 2023: 20.5%) and 25-34 years old (2018: 15.9%, 2023: 24.2%) had the highest prevalences of disclosure, whereas patients who were 75 years of age or older had the lowest prevalence of disclosure (2018: 1.9%, 2023: 4.6%). Patients who were 25-34 years old had the highest percent difference in disclosure rates of 8.3%, which corresponded to a 52.2% increase from 2018 to 2023. The adult age group with the highest percent change was patients who were 75 years of age or older, with a difference of 2.7%, which corresponded to a 142.1% increase from 2018 to 2023. Conclusions: These trends in preoperative self-reported cannabis use among patients undergoing orthopedic surgery have important implications for perioperative care and clinical outcomes. Efforts are underway to refine and standardize cannabis use data capture at our institution.

Keywords: orthopedic surgery, cannabis, postoperative pain, postoperative nausea

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Authors: Neeraj Vij, Christian Leber, Kenneth Schmidt

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Introduction: Total knee arthroplasty is a common procedure. It is well known that the biomechanics of the knee do not fully return to their normal state. Motion analysis has been used to study the biomechanics of the knee after total knee arthroplasty. The purpose of this scoping review is to summarize the current use of gait analysis in total knee arthroplasty and to identify the preoperative motion analysis parameters for which a systematic review aimed at determining the reliability and validity may be warranted. Materials and Methods: This IRB-exempt scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist strictly. Five search engines were searched for a total of 279 articles. Articles underwent a title and abstract screening process followed by full-text screening. Included articles were placed in the following sections: the role of gait analysis as a research tool for operative decisions, other research applications for motion analysis in total knee arthroplasty, gait analysis as a tool in predicting radiologic outcomes, gait analysis as a tool in predicting clinical outcomes. Results: Eleven articles studied gait analysis as a research tool in studying operative decisions. Motion analysis is currently used to study surgical approaches, surgical techniques, and implant choice. Five articles studied other research applications for motion analysis in total knee arthroplasty. Other research applications for motion analysis currently include studying the role of the unicompartmental knee arthroplasty and novel physical therapy protocols aimed at optimizing post-operative care. Two articles studied motion analysis as a tool for predicting radiographic outcomes. Preoperative gait analysis has identified parameters than can predict postoperative tibial component migration. 15 articles studied motion analysis in conjunction with clinical scores. Conclusions: There is a broad range of applications within the research domain of total knee arthroplasty. The potential application is likely larger. However, the current literature is limited by vague definitions of ‘gait analysis’ or ‘motion analysis’ and a limited number of articles with preoperative and postoperative functional and clinical measures. Knee adduction moment, knee adduction impulse, total knee range of motion, varus angle, cadence, stride length, and velocity have the potential for integration into composite clinical scores. A systematic review aimed at determining the validity, reliability, sensitivities, and specificities of these variables is warranted.

Keywords: motion analysis, joint replacement, patient-reported outcomes, knee surgery

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Authors: Hossam Mohamed Abdelfattah Helal Hegazi

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Winds and storms are considered crucial weathering factors, representing primary causes of destruction and erosion for all materials on the Earth's surface. This naturally includes historical structures, with the impact of winds and storms intensifying their deterioration, particularly when carrying high-hardness sand particles during their passage across the ground. Ancient Egyptians utilized various methods to prevent wind damage to their ancient architecture throughout the ancient Egyptian periods . One of the techniques employed by ancient Egyptians was the use of clay or compacted earth as a filling material between opposing walls made of stone, bricks, or mud bricks. The walls made of reeds or woven tree branches were covered with clay to prevent the infiltration of winds and rain, enhancing structural integrity, this method was commonly used in hollow layers . Additionally, Egyptian engineers innovated a type of adobe brick with uniformly leveled sides, manufactured from dried clay. They utilized stone barriers, constructed wind traps, and planted trees in rows parallel to the prevailing wind direction. Moreover, they employed receptacles to drain rainwater resulting from wind-loaded rain and used mortar to fill gaps in roofs and structures. Furthermore, proactive measures such as the removal of sand from around historical and archaeological buildings were taken to prevent adverse effects

Keywords: winds, storms, weathering, destruction, erosion, materials, Earth's surface, historical structures, impact

Procedia PDF Downloads 62

Authors: Robert G. Nini

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The quality of road pavement is affected mostly by the type of sub-grade which is acting as road foundation. The roads degradation is related to many factors especially the climatic conditions, the quality, and the thickness of the base materials. The thickness of this layer depends on its California Bearing Ratio (CBR) test value which by its turn is highly affected by the quantity of water infiltrated under the road after heavy rain. The capacity of the base material to drain out its water is predominant factor because any change in moisture content causes change in sub-grade strength. This paper studies the effect of the soaking period of soil especially clay on its CBR value. For this reason, we collected many clayey samples in order to study the effect of the soaking period on its CBR value. On each soil, two groups of experiments were performed: main tests consisting of Proctor and CBR test from one side and from other side identification tests consisting of other tests such as Atterberg limits tests. Each soil sample was first subjected to Proctor test in order to find its optimum moisture content which will be used to perform the CBR test. Four CBR tests were performed on each soil with different soaking period. The first CBR was done without soaking the soil sample; the second one with two days soaking, the third one with four days soaking period and the last one was done under eight days soaking. By comparing the results of CBR tests performed with different soaking time, a more detailed understanding was given to the role of the water in reducing the CBR of soil. In fact, by extending the soaking period, the CBR was found to be reduced quickly the first two days and slower after. A precise reduction factor of the CBR in relation with soaking period was found at the end of this paper.

Keywords: California Bearing Ratio, clay, proctor test, soaking period, sub-grade

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Authors: Cassey Younghans

Abstract:

Background: Current health care trends demonstrate that there is an increasing number of patients being hospitalized with complex comorbidities. These complex needs require advanced therapies, and treatment goals often focus on doing everything possible to prolong life rather than focusing on the individual patient’s quality of life which is the goal of palliative care efforts. Patients benefit from palliative care in the early stages of the illness rather than after the disease progressed or the state of acuity has advanced. The clinical problem identified was that palliative care was not being implemented early enough in the disease process with patients who had complex medical conditions and who would benefit from the philosophy and skills of palliative care professionals. Purpose: The purpose of this quality improvement study was to increase the number of palliative care screenings and consults completed on adults after being admitted to one Non-ICU and Non-COVID hospital unit. Methods: A retrospective chart review assessing for possible missed opportunities to introduce palliation was performed for patients with six primary diagnoses, including heart failure, liver failure, end stage renal disease, chronic obstructive pulmonary disease, cerebrovascular accident, and cancer in a population of adults over the ago of 19 on one medical-surgical unit over a three-month period prior to the intervention. An educational session with the nurses on the benefits of palliative care was conducted by the researcher, and a screening tool was implemented. The expected outcome was to have an increase in early palliative care consultation with patients with complex comorbid conditions and a decrease in missed opportunities for the implementation of palliative care. Another retrospective chart review was completed following completion of the three month piloting of the tool. Results: During the retrospective chart review, 46 patients were admitted to the medical-surgical floor with the primary diagnoses identified in the inclusion criteria. Six patients had palliative care consults completed during that time. Twenty-two palliative care screening tools were completed during the intervention period. Of those, 15 of the patients scored a 7 or higher, suggesting that a palliative care consultation was warranted. The final retrospective chart review identified that 4 palliative consults were implemented during that time of the 31 patients who were admitted over the three month time frame. Conclusion: Educating nurses and implementing a palliative care screening upon admission can be of great value in providing early identification of patients who might benefit from palliative care. Recommendations – It is recommended that this screening tool should be used to help identify the patents of whom would benefit from a palliative care consult, and nurses would be able to initiated a palliative care consultation themselves.

Keywords: palliative care, screening, early, palliative care consult

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Authors: Grace C. Kuroki, Yixin Hu, Bailey Surtees, Rebecca Krimins, Nicholas J. Durr, Dara L. Kraitchman

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The purpose of this study was to perform a Phase I veterinary clinical trial with a low-cost, carbon-dioxide-based, passive thaw cryoablation device as proof-of-principle for application in pets and translation to third-world treatment of breast cancer. This study was approved by the institutional animal care and use committee. Client-owned dogs with subcutaneous masses, primarily lipomas or mammary cancers, were recruited for the study. Inclusion was based on clinical history, lesion location, preanesthetic blood work, and fine needle aspirate or biopsy confirmation of mass. Informed consent was obtained from the owners for dogs that met inclusion criteria. Ultrasound assessment of mass extent was performed immediately prior to mass cryoablation. Dogs were placed under general anesthesia and sterilely prepared. A stab incision was created to insert a custom 4.19 OD x 55.9 mm length cryoablation probe (Kubanda Cryotherapy) into the mass. Originally designed for treating breast cancer in low resource settings, this device has demonstrated potential in effectively necrosing subcutaneous masses. A dose escalation study of increasing freeze-thaw cycles (5/4/5, 7/5/7, and 10/7/10 min) was performed to assess the size of the iceball/necrotic extent of cryoablation. Each dog was allowed to recover for ~1-2 weeks before surgical removal of the mass. A single mass was treated in seven dogs (2 mammary masses, a sarcoma, 4 lipomas, and 1 adnexal mass) with most masses exceeding 2 cm in any dimension. Mass involution was most evident in the malignant mammary and adnexal mass. Lipomas showed minimal shrinkage prior to surgical removal, but an area of necrosis was evident along the cryoablation probe path. Gross assessment indicated a clear margin of cryoablation along the cryoprobe independent of tumor type. Detailed histopathology is pending, but complete involution of large lipomas appeared to be unlikely with a 10/7/10 protocol. The low-cost, carbon dioxide-based cryotherapy device permits a minimally invasive technique that may be useful for veterinary applications but is also informative of the unlikely resolution of benign adipose breast masses that may be encountered in third world countries.

Keywords: cryoablation, cryotherapy, interventional oncology, veterinary technology

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Authors: Narges Solaymani

Abstract:

medical training of patients. Nursing is a very important profession in the societies of the world. Although in the past, all caregivers of the sick and disabled were called nurses, nowadays, a nurse is a person who has a university education in this field. There are nurses in bachelor's, master's, and doctoral degrees in nursing. New courses have been launched in the master's degree based on duty-oriented nurses. A nurse cannot have an independent treatment center but is a member of the treatment team in established treatment centers such as hospitals, clinics, or offices. Nurses can establish counseling centers and provide nursing services at home. According to the standards, the number of nurses should be three times the number of doctors or twice the number of hospital beds, or there should be three nurses for every thousand people. Also, international standards show that in the internal and surgical department, every 4 to 6 patients should have a nurse.

Keywords: Nurse, Intensive Care, CPR, Bandage

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Authors: Minna Salim, James Brady

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Postoperative nausea and pain (PONV) are adverse effects following surgical procedures. It is especially pronounced in patients undergoing orthognathic surgery, as their mouth is closed postoperatively using wires or rubber bands. Postoperative mouth closure increases the discomfort and risk of complications associated with nausea and vomiting. Many surgeons and institutions apply gastric decompression in hopes of aspirating stomach contents and, therefore, decreasing PONV incidence. This review observed that PONV incidence was not affected by gastric decompression overall. However, the effect of gastric decompression on PONV in orthognathic surgery was variable. This paper aims to summarize the findings of gastric decompression on PONV and to determine the need for it in orthognathic surgery.

Keywords: gastric decompression, nasogastric tube, orthognathic surgery, postoperative nausea, vomiting

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Authors: Syed Toqueer Akhter, Hussain Hamid

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Over the last few decades an upward trend has been observed in the case of labor migration from Pakistan. The emigrants are not just economically motivated and in search of a safe living environment towards more developed countries in Europe, North America and Middle East. The opportunity cost of migration comes in the form of brain drain that is the loss of qualified and skilled human capital. Throughout the history of Pakistan, situations of political instability have emerged ranging from violation of political rights, political disappearances to political assassinations. Providing security to the citizens is a major issue faced in Pakistan due to increase in crime and terrorist activities. The aim of the study is to test the impact of political instability, appearing in the form of political terror, violation of political rights and civil liberty on skilled migration of labor. Three proxies are used to measure the political instability; political terror scale (based on a scale of 1-5, the political terror and violence that a country encounters in a particular year), political rights (a rating of 1-7, that describes political rights as the ability for the people to participate without restraint in political process) and civil liberty (a rating of 1-7, civil liberty is defined as the freedom of expression and rights without government intervention). Using time series data from 1980-2011, the distributed lag models were used for estimation because migration is not a onetime process, previous events and migration can lead to more migration. Our research clearly shows that political instability appearing in the form of political terror, political rights and civil liberty all appeared significant in explaining the extent of skilled migration of Pakistan.

Keywords: skilled labor migration, political terror, political rights, civil liberty, distributed lag model

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Authors: Esra Yuce, Isil D. S. Yamaner, Murude Yazan

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Aims and objective: Antiresorptive agents including bisphosphonates and denosumab as strong suppressors of osteoclasts are the most commonly used antiresorptive medications for the treatment of osteoporosis which counteract the negative quantitative alteration of trabecular and cortical bone by inhibition of bone turnover. Oral bisphosphonate therapy for the treatment of osteopenia, osteoporosis or Paget's disease is associated with the low-grade risk of osteonecrosis of the jaw, while higher-grade risk is associated with receiving intravenous bisphosphonates therapy in the treatment of multiple myeloma and bone metastases. On the other hand, there has been a remarkable increase in incidences of antiresorptive related osteonecrosis of the jaw (ARONJ) in oral bisphosphonate users. This clinical presentation will evaluate the healing outcomes via piezoelectric bone surgery under the irrigation of PVP-I solution irrigation in patients received bisphosphonate therapy. Material-Method: The study involved 8 female and 5 male patients that have been treated for ARONJ. Among 13 necrotic sites, 9 were in the mandible and 4 were in the maxilla. All of these 13 patients treated with surgical debridement via piezoelectric bone surgery under irrigation by solution with 3% PVP-I concentration in combination with long-term antibiotic therapy and 5 also underwent removal of mobile segments of bony sequestrum. All removable prosthesis in 8 patients were relined with soft liners during the healing periods in order to eliminate chronic minor traumas. Results: All patients were on oral bisphosphonate therapy for at least 2 years and 5 of which had received intravenous bisphosphonates up to 1 year before therapy with oral bisphosphonates was started. According to the AAOMS staging system, four cases were stage II, eight cases were stage I, and one case was stage III. The majority of lesions were identified at sites of dental prostheses (38%) and dental extractions (62%). All patients diagnosed with ARONJ stage I had used unadjusted removable prostheses. No recurrence of the symptoms was observed during the present follow-up (9–37 months). Conclusion: Despite their confirmed effectiveness, the prevention and treatment of osteonecrosis of the jaw secondary to oral bisphosphonate therapy remain major medical challenges. Treatment with piezoelectric bone surgery with irrigation of povidone-iodine solution was effective for management of bisphosphonate-related osteonecrosis of the jaw. Taking precautions for patients treated with oral bisphosphonates, especially also denture users, may allow for a reduction in the rate of developing osteonecrosis of the maxillofacial region.

Keywords: antiresorptive drug related osteonecrosis, bisphosphonate therapy, piezoelectric bone surgery, povidone iodine

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